Citation Nr: 0307455 Decision Date: 04/18/03 Archive Date: 04/24/03 DOCKET NO. 96-23 613 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to service connection for cardiovascular disease, to include hypertension and atherosclerotic heart disease, secondary to post-traumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD M. Taylor, Associate Counsel INTRODUCTION The veteran had active service from May 1966 to May 1968. His DD Form 214 shows that he is in receipt of a Purple Heart Medal. This matter comes before the Board of Veterans Appeals (Board) on appeal from rating decisions of the Chicago, Illinois, Department of Veterans Affairs (VA) Regional Office (RO). This case has previously come before the Board. In September 1999, the Board remanded the case to the RO for further development. The veteran was afforded a travel Board hearing before the undersigned member of the Board in June 2002. A transcript of the hearing has been associated with the claims folder. FINDING OF FACT The veteran's service-connected PTSD caused or aggravated cardiovascular disease, to include hypertension and atherosclerotic heart disease. CONCLUSION OF LAW Cardiovascular disease, to include hypertension and atherosclerotic heart disease, is proximately due to or the result of PTSD. 38 C.F.R. § 3.310 (2002). REASONS AND BASES FOR FINDING AND CONCLUSION VCAA There has been a significant change in the law during the pendency of this appeal with the enactment of the Veterans Claims Assistance Act of 2000, (codified at 38 U.S.C.A. §§ 5102, 5103, 5103A, and 5107); 66 Fed. Reg. 45,620 (Aug 29, 2001) (codified as amended at 38 C.F.R. § 3.159 (2001) (hereafter "VCAA"). The new law includes an enhanced duty to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The VCAA is applicable to all claims filed on or after the date of enactment, November 9, 2000, or filed before the date of enactment and not yet final as of that date. VCAA. See also Karnas v. Derwinski, 1 Vet. App. 308 (1991). In this case, even though the RO did not have the benefit of the explicit provisions of the VCAA, VA's duties have been fulfilled. The Board notes that in view of the fact that the veteran's claim is herein granted, any deficiencies in regard to VCAA, to include the relevant provisions pertaining to notice and assistance, are harmless. Analysis The veteran has appealed the denial of service connection for cardiovascular disease, to include hypertension and atherosclerotic heart disease. In essence, he has asserted that cardiovascular disease, to include hypertension and atherosclerotic heart disease, is associated with service- connected PTSD. Service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. The term, disability, as contemplated by the VA regulations, means "impairment in earning capacity resulting from all types of diseases or injuries encountered as a result of or incident to military service and their residual conditions. The term disability as used in 38 U.S.C.A. § 1110 refers to impairment of earning capacity, and the definition mandates that any additional impairment in earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, shall be compensated. Thus, pursuant to 38 U.S.C.A. § 1110 and 38 C.F.R. § 3.310(a), when aggravation of a veteran's non- service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). In this case, there is both positive and negative evidence. The veteran is service-connected for PTSD, and cardiovascular, hypertension and atherosclerotic heart disease have been diagnosed. The June 1993 VA examiner stated that studies showed that there was a link between cardiovascular disease and stress. However, there was neither positive nor evidence linking vascular disease to PTSD. The August 1993 VA examiner opined that increasing PTSD symptoms had possibly interfered with his health, specifically, a history of coronary artery disease. Although these examiners have qualified their opinions in terms of absolute certainty, the Board finds that coupled with the other opinions of record, they have some probative value as to this particular veteran. The December 2002 VA examiner stated that medical literature supported the assumption that cardiac disease was secondary to the effects of hypertension, and that if hypertension could be associated with PTSD, then his cardiac disease could be associated with PTSD. He stated that such a determination was properly made by a psychiatrist. However, it was his reluctant opinion that there was no relationship between PTSD and hypertension and ischemic heart disease. In a psychiatric report from Dr. L. M., received in February 2003, the physician stated that based on a review of pertinent literature from various medical journals, he had drawn the following conclusions: 1. Psychosocial stress played an important causative role in the development of hypertension. He commented that for many, if not most, war veterans, wartime experience had proven to be the greatest source of ongoing psychosocial stress throughout their lifetime. He stated that it was reasonable to conclude that wartime experience often played a causative role in the development of hypertension. 2. Veterans suffering from PTSD, noted to be the prototypical anxiety disorder, were at increased risk for developing hypertension. Dr. L. M. added that to the extent that some might argue that it was highly unlikely that wartime experience was causally related to hypertension based on the fact that the hypertension was not diagnosed or discovered for many years after service, such a contention was easily refuted. Specifically, he stated that since blood pressure rose with age in Western civilizations, the veteran would not have needed to be fully hypertensive at the time of discharge, but might have only experienced a modest (sub-clinical) increase in blood pressure, which when added to the normal increment associated with aging, would ultimately develop into hypertension. He added that the veteran's body had been responding physiologically to stress, not just during the time of combat, but probably almost daily for the ensuing years, by virtue of his PTSD symptoms. He unequivocally concluded that what might have appeared to be a disconnected, future manifestation of a past trauma, might have actually represented the cumulative effect of years of stress and the body's response to it. Weighed against the above opinions is the Dr. J. B.'s blanket statement to the effect that there was no relationship between PTSD and coronary artery disease. Dr. J. B neither examined the veteran nor reviewed his C-file. In fact, it does not appear that the opinion was written specifically in regard to this veteran. Thus, the Board finds this opinion to have diminished probative value The Board is under an obligation to review all the evidence of record and resolve doubt in favor of the veteran. The Board finds that the psychiatric opinion received in February 2003 contains thorough rationale, based on a wealth of medical literature and expertise. This opinion clearly links the veteran's cardiovascular disease to his symptoms of service-connected PTSD. This opinion is supported by other opinions of record, which suggest the possibility of a relationship between cardiovascular disease and PTSD symptoms. Weighed against the August 1986 opinion, which is lacking in authoritative quality, the Board finds that there is sufficient evidence in support of the claim. The legal basis for a denial of a claim is that a preponderance of the evidence is against the claim. Based on the opinions in this file, a preponderance of the evidence is not against the claim and service connection for cardiovascular disease, to include hypertension and atherosclerotic heart disease, is granted. ORDER Service connection for cardiovascular disease, to include hypertension and atherosclerotic heart disease, is granted ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.